Discussion: Triage Scheme in Disaster Emergency

Discussion: Triage Scheme in Disaster Emergency ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Triage Scheme in Disaster Emergency I have to submit an annotation bibliography of 10 references within the upcoming two days. I should choose a topic about Triage scheme in disaster/Emergency management. Discussion: Triage Scheme in Disaster Emergency Use APA Style Choose credible sources (peer-reviewed) I attached some articles Attachment preview Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients Frank J. Voskens, MD; Eveline A. J. van Rein, BSc; Rogier van der Sluijs, BSc; Roderick M. Houwert, MD, PhD; Robert Anton Lichtveld, MD, PhD; Egbert J. Verleisdonk, MD, PhD; Michiel Segers, MD; Ger van Olden, MD, PhD; Marcel Dijkgraaf, PhD; Luke P. H. Leenen, MD, PhD; Mark van Heijl, MD, PhD A dequate prehospital trauma triage of injured patients is imperative for optimal trauma care. In an inclusive trauma system, it is essential to transport patients with severe injuries to a level I trauma center and patients without severe injuries to lower-level hospitals. 1,2 Previous studies have clearly shown lower mortality rates in patients Discussion: Triage Scheme in Disaster Emergency with severe injuries treated at a level I trauma center compared with patients treated at a lower-level hospitals.1-6 Management of care of the injured trauma patient on the scene of injury remains challenging, and situations can be chaotic. After a rapid trauma assessment of clinical and physiological parameters, emergency medical services (EMS) professionals must identify patients at risk for severe injury and select the proper destination. Prehospital triage protocols are used to help define the patient destination. However, triage of patients without evident abnormality and instability at presentation remains challenging given the limited facilities on scene. In the Netherlands, allocation of trauma patients to the appropriate level of trauma care is guided by the Dutch Field Triage Protocol (version 7.1, National Protocol of Ambulance Services),7 for EMS professionals (Figure 1). This protocol is based on the Field Triage Decision Scheme established by the American College of Surgeons Committee on Trauma (ACS-COT).8,9 Quality of prehospital triage can be determined by rates of undertriage and overtriage. Undertriage is defined as the proportion of patients with severe injuries not transported to a IMPORTANCE A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. OBJECTIVE To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. Discussion: Triage Scheme in Disaster Emergency DESIGN, SETTING, AND PARTICIPANTS Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. MAIN OUTCOMES AND MEASURES The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. RESULTS A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. CONCLUSIONS AND RELEVANCE More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol. Discussion: Triage Scheme in Disaster Emergency accuracy_of_prehospital_triage_in_selecting.pdf comparing_the_air_medical_prehospital_triage_score_with_current_practice_for_triage_of_injured_patients_to_helicopter_emergency_medical_services.pdf head_to_head_comparison_of_disaster_triage_methods_in.pdf Research JAMA Surgery | Original Investigation Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients Frank J. Voskens, MD; Eveline A. J. van Rein, BSc; Rogier van der Sluijs, BSc; Roderick M. Houwert, MD, PhD; Robert Anton Lichtveld, MD, PhD; Egbert J. Verleisdonk, MD, PhD; Michiel Segers, MD; Ger van Olden, MD, PhD; Marcel Dijkgraaf, PhD; Luke P. H. Leenen, MD, PhD; Mark van Heijl, MD, PhD Invited Commentary page 328 IMPORTANCE A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. OBJECTIVE To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. DESIGN, SETTING, AND PARTICIPANTS Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. MAIN OUTCOMES AND MEASURES The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. RESULTS A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. CONCLUSIONS AND RELEVANCE More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol. JAMA Surg. 2018;153(4):322-327. doi:10.1001/jamasurg.2017.4472 Published online November 1, 2017. A dequate prehospital trauma triage of injured patients is imperative for optimal trauma care. In an inclusive trauma system, it is essential to transport patients with severe injuries to a level I trauma center and patients without severe injuries to lower-level hospitals. 1,2 Previous studies have clearly shown lower mortality rates in patients with severe injuries treated at a level I trauma center compared with patients treated at a lower-level hospitals. Discussion: Triage Scheme in Disaster Emergency 1-6 Management of care of the injured trauma patient on the scene of injury remains challenging, and situations can be chaotic. After a rapid trauma assessment of clinical and physiological parameters, emergency medical services (EMS) professionals must identify patients at risk for severe injury and select the proper destination. Prehospital triage 322 Author Affiliations: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands (Voskens, van Rein, van der Sluijs, Houwert, Leenen, van Heijl); Utrecht Trauma Center, Utrecht, the Netherlands (Houwert); Regional Ambulance Facility Utrecht, Regionale Ambulance Voorziening Utrecht, Utrecht, the Netherlands (Lichtveld); Department of Surgery, Diakonessenhuis Utrecht/Zeist/ Doorn, Utrecht, the Netherlands (Verleisdonk); Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands (Segers); Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands (van Olden); Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands (Dijkgraaf). Corresponding Author: Frank J. Voskens, MD, Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands ([email protected]). protocols are used to help define the patient destination. However, triage of patients without evident abnormality and instability at presentation remains challenging given the limited facilities on scene. In the Netherlands, allocation of trauma patients to the appropriate level of trauma care is guided by the Dutch Field Triage Protocol (version 7.1, National Protocol of Ambulance Services),7 for EMS professionals (Figure 1). This protocol is based on the Field Triage Decision Scheme established by the American College of Surgeons Committee on Trauma (ACS-COT).8,9 Quality of prehospital triage can be determined by rates of undertriage and overtriage. Undertriage is defined as the proportion of patients with severe injuries not transported to a JAMA Surgery April 2018 Volume 153, Number 4 (Reprinted) © 2017 American Medical Association. All rights reserved. Downloaded from jamanetwork.com by Thomas Jefferson University East Falls Campus user on 01/29/2019 jamasurgery.com Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients level I trauma center. Overtriage is defined as the proportion of patients without severe injuries transported to a level I trauma center. Undertriage results in higher mortality and delay of adequate care, whereas overtriage limits the available level I resources for patients without severe injuries.2,8 To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system or region. Discussion: Triage Scheme in Disaster Emergency The benchmark level in the ACS-COT guidelines is a maximum undertriage rate of 5%, allowing for an overtriage rate of up to 50%.8 In a Dutch population consisting of high-energy trauma patients only, the undertriage rate was 11%.10 The quality of triage in the complete trauma population is unknown. This present study aims to evaluate the quality of the Dutch field triage protocol for identifying severely injured trauma patients in a population consisting of adult trauma patients transported by EMS professionals with the highest priority in the Central Netherlands region. Methods Study Design and Setting The present study was performed in the Central Netherlands region using prospectively collected prehospital and hospital data of all adult trauma patients transported with the highest priority by the Regional Ambulance Service Utrecht to 1 of the 10 hospitals in Central Netherlands Original Investigation Research Key Points Question What is the quality of the field triage system to identify severely injured adult trauma patients? Findings This study included 4950 trauma patients and shows that more than 20% of the patients with severe injuries were not transported to a level I trauma center. Meaning A significant group of severely injured trauma patients does not receive the appropriate level I trauma care, putting these patients at risk for increased morbidity and mortality; improvement of prehospital triage is necessary. between January 2012 and July 2014. The region Central Netherlands consists of 9 level II and level III hospitals and 1 level I trauma center in a 2418-km2 region with a population of 1.2 million people. The University Medical Center Utrecht is designated as a level I trauma center, offering trauma care at the highest level for severely injured patients. The 9 surrounding level II and III hospitals are designed to treat patients without severe injuries. This regional trauma network is based on an inclusive and integrated trauma system.8 The ambulance care system is nurse-based. Ambulance nurses are licensed to administer medical treatment at advanced life support level, and ambulance drivers are qualified to provide medical assistance to the ambulance nurses. The present study protocol was reviewed and approved by the local medical ethical committee, and patient consent was waived. Analyses began in 2016. Figure 1. The Field Triage Protocol for the Distribution of Trauma Patients Over Different Hospitals ABC unstable RTS <11/PTS <9 Deteriorating GCS score GCS score, <9 Flail chest Amputation proximal to wrist/ankle ?2 Fractures (femur and/or humerus) Penetrating injury of head/thorax or abdomen Unstable pelvic fracture Body temperature ?32°C Neurologic deficit (?1 extremity) Pupil difference Yes No Fast/severe deterioration Yes Level I, II, or III RTS 11 Inhalation injury Burns >15% Chemical trauma No Yes Level I Fast/severe deterioration No Yes Level I, II, or III jamasurgery.com No Fall of height at ?5 m or ?3 times body height Car crash at >65 km/h Motor crash at >32 km/h Vehicle deformity, >50 cm Vehicle intrusion passenger compartment >30 cm Vehicle rollover Passenger ejection from vehicle Fatality in same vehicle Car-pedestrian or car-bicycle impact at >8 km/h Pregnancy at >13 wk No Level I or II No Level I, II, or III ABC indicates airway, breathing, and circulation; GCS, Glasgow Coma Scale; PTS, Pediatric Trauma Score; RTS, Revised Trauma Score. (Reprinted) JAMA Surgery April 2018 Volume 153, Number 4 © 2017 American Medical Association. Discussion: Triage Scheme in Disaster Emergency All rights reserved. Downloaded from jamanetwork.com by Thomas Jefferson University East Falls Campus user on 01/29/2019 323 Research Original Investigation Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients Figure 2. Flowchart of Patient Enrollment 6581 Trauma patients transported with the highest emergency between 2012 and 2014 1631 Excluded 873 Transferred to a hospital outside the region 695 Aged <16 y 63 Missing data at receiving hospital 1518 In-hospital data of the Dutch national trauma database register 3432 Retrospectively collected data of the electronic patient documentation at receiving hospital 4950 Eligible patients to the data set. For this part of the analysis, undertriage was defined as the proportion of patients with severe injuries not identified by the prehospital trauma triage protocol, divided by the total number of severely injured patients. Overtriage was defined as the proportion of patients without severe injuries identified as severely injured patients using the prehospital trauma triage protocol. Prehospital level I criteria were penetrating injury (head, thorax, and/or abdomen), 2 or more fractures of long bones (humerus and/or femur), amputation proximal to wrist or ankle, neurologic failure in 1 or more extremity, unstable pelvic fracture, pupil difference, flail chest, Glasgow Coma Scale score more than 9, deteriorating Glasgow Coma Scale score, Revised Trauma Score less than 11, vitally compromised in airway and breathing or circulation, and body temperature of 32°C or more. Finally, the compliance of EMS professionals for correct transportation of patients with prehospital level I trauma center criteria according to the Dutch field triage protocol was determined. Patients All trauma patients 16 years and older transported by EMS professionals with the highest priority were included in the study. Patients transported to a hospital outside Central Netherlands and patients transported by helicopter were excluded. Patients were also excluded if insufficient data were available in the receiving hospital to properly calculate the Injury Severity Score (ISS). Data Collection Prehospital reports from EMS professionals were prospectively collected and included patient demographics, description of the trauma mechanism, physical examination data on site, prehospital treatment, and receiving hospital. Furthermore, the report included a standardized digital report of specific vital parameters, ie, Glasgow Coma Scale score, respiratory rate, systolic blood pressure level, heart rate, pupil deficit, and Revised Trauma Score. The Dutch national trauma database registers in-hospital data regarding injuries and complications for all trauma patients admitted to a hospital. For patients who were discharged from the emergency department, data were extracted from the electronic patient documentation. Injuries were encoded according to the Abbreviated Injury Scale 90 Update 98.11 Injury Severity Scores were calculated and used to assess overall injury severity. Discussion: Triage Scheme in Disaster Emergency Outcome Severe injury was defined as an ISS of 16 or more. The primary outcome of this study was the quality of the field triage system in terms of undertriage and overtriage. Undertriage was defined as the proportion of severely injured patients (ISS, ?16) erroneously transported to level II or III hospitals. Overtriage was defined as the proportion of patients with an ISS of less than 16 transported to a level I trauma center.8,12,13 The diagnostic accuracy of the Dutch field triage protocol was calculated for identifying patients with or without severe injuries, regardless of actual destination facility. For this purpose, the level I triage criteria were retrospectively applied 324 Statistical Analysis Data were analyzed using descriptive statistics, and results were shown in frequencies and percentages. Undertriage and overtriage rates were presented with 95% CI. Multiple imputation was used for missing prehospital values and was performed with SPSS IBM statistical software (version 23.0). Missing values were predicted based on all other predictors, as well as the outcome (ISS). All logistic regression analyses were performed on 5 imputed data sets independently and pooled afterwards for missing prehospital values. Multiple imputation for missing prehospital values has been previously validated.14 Multiple imputation was used for pulse in 6.76%, respiratory rate in 6.52%, systolic blood pressure in 6.96%, Revised Trauma Score in 8.14%, and Glasgow Coma Scale score in 4.59%. Results A total of 6581 trauma patients were transported by EMS professionals with the highest priority in Central Netherlands. Inclusion criteria were met in 4950 patients for the current analysis (Figure 2). Characteristics of the study sample are shown in Table 1. Patients were relatively equally distributed between the hospitals: level I, 1724 patients (34.8%); level II, 1326 patients (26.8%); and level III, 1900 patients (38.4%). The median age was 45 years, 2887 were male (58.3%), and 436 had an ISS of 16 or more (8.8%). Severe injury in 1 of the body regions (Abbreviated Injury Scale score, ?3) was most frequently diagnosed in the head and extremities. Of 436 patients with severe injuries, 94 were erroneously transported to level II or level III hospitals, resulting in an undertriage of 21.6% (95% CI, 18.0-25.7). Transportation of 1382 of 4514 patients without severe injuries to the level I trauma center resulted in an overtriage of 30.6% (95% CI, 29.3-32.0) (Table 2). The diagnostic accuracy of the Dutch field triage protocol is shown in Table 2. The protocol-based undertriage was 63.8% (95% CI, 59.2-68.1), and the protocol-based overtriage was 7.4% JAMA Surgery April 2018 Volume 153, Number 4 (Reprinted) © 2017 American Medical Association. All rights reserved. Downloaded from jamanetwork.com by Thomas Jefferson University East Falls Campus user on 01/29/2019 jamasurgery.com Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients Table 1. Characteristics of the Study Population Variable Patients, No. (%) (N = 4950) Male 2887 (58.3) Age, median (IQR), y Elderly adults (>65 y) Prehospital GCS score <9 Original Investigation Research Table 2. Discussion: Triage Scheme in Disaster Emergency Quality of Field Triage System Regarding Correct Destination Facility for Patients With and Without Severe Injuries 45 (27-63) Variable Patients With Severe Injuries (ISS, ?16) (n = 436) Patients Without Severe Injuries (ISS, <16) (n = 4514) 342 (78.4) 1382 (30.6) Quality of field triage system regarding correct destination facility for patients with and without severe injuries 1085 (21.9) 141 (2.8) Triage criteria Level I trauma center, No. (%) Mechanism of injury 1300 (26.3) Physiological criteria 289 (5.8) Level II/III trauma center, No. (%) 94 (21.6) 3132 (69.4) Injury criteria 256 (5.2) Undertriage, % (95% CI)a 21.6 (18-25.7) NA 119 (2.4) Overtriage, % (95% CI)b Assistance of air medical services Out-of-hospital intubation Transfer to Level I trauma center 1724 (34.8) Level II trauma center 1326 (26.8) Level III trauma center 1900 (38.4) ISS, median (IQR) NA 2 (1-5) Level I trauma center indication, No. (%) 158 (36.2) 334 (7.4) No level I trauma center indication, No. (%) 278 (63.8) 4180 (92.6) c Severely injured (ISS, ?16) Undertriage, % (95% CI) 436 (8.8) Overtriage, % (95% CI)d AIS score ?3 per region Head and neck Face Thorax Abdomen Extremities External In-hospital stay Mortality 435 (8.8) 26 (0.5) 318 (6.4) 61 (1.2) Abbreviations: AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; IQR, interquartile range; ISS, Injury Severity Score. (95% CI, 6.7-8.2). The compliance of EMS professionals to the field triage was 72.6%. Overall, 30% of the patients with a positive injury and/or physiology criteria were not transported to a level 1 trauma center. Table 3 illustrates the undertriage and overtriage rates for different subgroups of the study population regarding correct destination facility. The undertriage rate in elderly patients is high at 38.6% (95% CI, 30.8-47.2). A high-energy trauma mechanism resulted in an undertriage rate of 9.1% (95% CI, 5.8-14.2). The group of patients with a positive injury and/or physiological criteria showed low undertriage rates (0% and 2.6%, respectively). Discussion: Triage Scheme in Disaster Emergency Discussion This study presents a quality assessment of prehospital triage in identifying severely injured trauma patients using prospectively collected data. Prehospital data were collected from EMS professionals and included every type of trauma patient transported with the highest priority, whether admitted or discharged from the emergency department in all types of hospitals. The quality of the Dutch field triage protocol remains relatively low. The overall rate of undertriage of the prehospital jamasurgery.com 7.4 (6.7-8.2) a Proportion of patients with severe injuries (ISS, ?16) not transported to level I trauma center. b Proportion of patients without severe injuries (ISS, <16) transported to level I trauma center. c Proportion of patients with severe injuries (ISS, ?16) without positive prehospital level I criteria according to the field triage protocol. d Proportion of patients without severe injuries (ISS, <16) with positive prehospital level I criteria according to the field triage protocol. 12 (0.2) 2047 (41.4) 63.8 (59.2-68.1) NA NA Abbreviations: ISS, Injury Severity Score; NA, not applicable. 61 (1.2) 496 (10.0) 30.6 (29.3-32) Diagnostic accuracy of the Dutch prehospital field triage protocol for identifying patients with and without severe injuries 49 (1.0) trauma triage system was 22% and is significantly higher than the benchmark level of 5%, as set by the ACS-COT.15 This implies that a significant group of trauma patients with severe injuries does not receive the appropriate level I trauma care. These patients are therefore at risk for increased morbidity and mortality.6,8,16 A variety of causes can be identified for undertriage. Closer examination of the elderly patients (aged ?65 years) in the present study showed a high undertriage rate of 39%. The undertriage rate among the elderly patients was 25% higher compared with younger adults. These findings are in accordance with previous studies showing increased undertriage rates in elderly patients.17,18 Elderly patients tend to have more cognitive and physical impairments with preexisting comorbidity, and therefore low energy trauma mechanisms may result in serious injuries.18 Undertriage of elderly patients remains a substantial problem. Modifications to the adult criteria of the ACS-COT triage protocol have been made to accentuate these physiological and anatomical differences of the elderly population.19 However, the effect of these modifications has no … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10